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Segmentation in Suffolk and North East Essex

This page lays out the technical logic and definitions that underpin the Suffolk and North East Essex Integrated Care System population segmentation model. This model is used for adults, and work for children and young people is forthcoming.

Model structure and logic

• A segment refers to a group of the population. In our model, every patient goes into one and only one segment.
• A segment is defined by segment elements. Each segment element is a rule or set of related rules that can be evaluated as true or false. A patient meets the criteria for a segment if they meet the criteria for any segment element within that segment.
• Segment priority is used to deal with overlap. If a patient meets the criteria to fit into more than one segment, they go into the highest priority segment.

Segment definitions

Segment Name	Segment priority	Segment elements
Die well	1	Palliative care, End of life, End stage liver disease, End stage heart disease, End stage renal disease, End stage COPD
Age well	2	Hospitalised for hip fracture, Hospitalised for stroke, Hospitalised for a fall, Hospitalised for frailty, Dementia, Four or more LTCs, Severe frailty, Housebound, Has a carer
Stay well	3	One to three LTCs, Cancer, Moderate frailty
Feel well	4	Serious mental illness, Depression, Anxiety, Care contact for mental health, Hospitalised for mental health, Hospitalised for alcohol, Hospitalised for drugs, Hospitalised for self-harm, Hospitalised for homelessness
Be well	5	Hospitalised for emergency dentistry, Obese, Smoker, Increased alcohol risk, High alcohol risk
Live well	6	Does not meet the criteria for any other segment

Segment element definitions

Each segment element comprises of a codelist one or more clinical codes. These definitions are provided below. Where possible, definitions are taken from primary care domain reference set clusters. Where this is not possible, manual codelists have been used and will be populated in due course.

Anxiety

• Codelist: opensafely/anxiety-disorders
• Coding scheme: SNOMED CT
• Source: Open codelists
• Datasets: Primary care
• Rules: Any code in codelist

Cancer

• Codelist: CAN_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Care contact for mental health

• Codelist: ind_cc_mh
• Coding scheme: NA
• Source: PCD Refset Cluster
• Datasets: MHSDS
• Rules: Any care contact within MHSDS in last year

Dementia

• Codelist: DEM_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Depression

• Codelist: DEPR_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

End of life

• Codelist: ind_eol
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

End stage COPD

• Codelist: ind_end_stage_COPD
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

End stage heart disease

• Codelist: ind_end_stage_heart
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

End stage liver disease

• Codelist: ind_end_stage_liver
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

End stage renal disease

• Codelist: ind_end_stage_renal
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

Four or more LTCs

• Codelist: Long-term conditions
• Coding scheme: SNOMED CT
• Source: Long-term conditions
• Datasets: Primary care
• Rules: Any code in codelist for at least four LTCs

Has a carer

• Codelist: ind_has_carer
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

High alcohol risk

• Codelist: ind_high_alcohol_risk
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

Hospitalised for alcohol

• Codelist: ind_hosp_alcohol
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for a fall

• Codelist: ind_hosp_fall
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for drugs

• Codelist: ind_hosp_drug
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for emergency dentistry

• Codelist: ind_hosp_dentistry
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for frailty

• Codelist: ind_hosp_frailty
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for hip fracture

• Codelist: ind_hosp_hip
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for homelessness

• Codelist: ind_hosp_homeless
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for mental health

• Codelist: ind_hosp_mh
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for self-harm

• Codelist: ind_hosp_selfharm
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Hospitalised for stroke

• Codelist: ind_hosp_stroke
• Coding scheme: SNOMED CT, ICD10
• Source: Forthcoming
• Datasets: SUS
• Rules: Any A&E attendance or admission with code in codelist within last year

Housebound

• Codelist: ind_housebound
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

Increased alcohol risk

• Codelist: ind_increased_alcohol_risk
• Coding scheme: SNOMED CT
• Source: Forthcoming
• Datasets: Primary care
• Rules: Any code in codelist

Moderate frailty

• Codelist: MODFRAIL_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Obese

• Codelist: BMI_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist within the last 12 months where BMI value is over 30

One to three LTCs

• Codelist: Long-term conditions
• Coding scheme: SNOMED CT
• Source: Long-term conditions
• Datasets: Primary care
• Rules: Any code in codelist for one, two or three LTCs

Palliative care

• Codelist: PALCARE_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Serious mental illness

• Codelist: MH_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Severe frailty

• Codelist: SEVFRAIL_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

Smoker

• Codelist: SMOK_COD
• Coding scheme: SNOMED CT
• Source: PCD Refset Cluster
• Datasets: Primary care
• Rules: Any code in codelist

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